Download presentation
Presentation is loading. Please wait.
1
CAS –Strategy, Pitfalls, and Safety Issues
Ralf Langhoff
2
Ten Steps of Carotid Stenting
1. Vascular Access (femoral - brachial) 2. Angiographic evaluation 3. Guiding Sheath Placement 4. Crossing the Stenosis - without protection - with distal protection - with proximal protection 5. Lesion predilatation 6. Stent Deployment 7. Postdilatation 8. Removal of Protection Device 9. Final Angiographic Control 10. Sheath removal/ Access Care
3
Carotid Access Can I safely Get There? CCA Access
Distal Protection Device into ICA
4
Carotid Access Determinants
Aortic Arch Type CCA/ECA Disease Carotid Tortuosity
5
Different Types of the Aortic
Arch
6
Truncus bicaroticus
7
Prefered Catheters Aortic Arch Type I Vertebral tip Judkins right
Head Hunter JB 1 Berenstein Weinberg
8
Prefered Catheters Aortic Arch Type III JB 2 Newton Sidewinder Vitek
Catheter tip should be formed in abdominal aorta or subclavian artery
9
Accessing the CCA Tips Beware of adverse anatomy, ie.
Type II and III aortic arch Irregular contour of proximal CCA on angiography Kinking / coiling of CCA To avoid vessel wall trauma, use of soft and flexible catheters that do not scrape the aorta (prograde cath.) Go from the easiest to the more complex approach Don't try to hard for too long ! It is better to refer the patient to CEA than to inflict permanent damage!
10
Critical Issues Should I choose Guide Catheter or Guide Sheath?
Should I Keep Guide C/S In distal CCA or proximal CCA ? When do I Choose Large Size Guide C/S?
11
Critical Issues Should I choose Guide Catheter or Guide Sheath?
Individual Preference GC more stable, allows torque GS smaller size, smoother transition (No ledge effect) Carotid Tortuosity GC allows torque Remote Carotid access GC more stable
12
Situations where guiding catheter is preferred
Accessing the CCA Situations where guiding catheter is preferred Calcified aortic arch Elongated aortic root Ostial lesions of CCA Tandem lesions Bovine arch (left carotid) Tortuous common carotid Tortuous iliacs 8 Fr Guide in Aorta maybe of advantage
13
RCC 5 F Diagnostic 6 F Sheath
14
Accessing the CCA Conclusions
It is important to realize that embolic events may be elicited " on the way" to the target lesion, that is before the lesion has even been touched A skillful and cautious approach using appropriate endoluminal equipment may help to avoid emboli-related complications Access is the major issue The "easy parts" are EPD and Stentplacement
15
Carotid Filter Issues Should I Pre-dilate Before Filter Placement?
What to do with slow Flow/ Occlusion in a filter? Filter filled? Carotid Spasm? What to do when the retrieval sheath fails to advance? How to handle a detached filter?
16
Carotid Filter Issues Carotid Tortuosity Should I Pre-dilate Before
Filter Placement? Carotid Tortuosity Fixed Wire Filters Pre-dilate severe stenosis Reduces friction during filter travel Bare Wire Filters No need to pre-dilate In-situ Wire Filters (Spyder) No need to pre-dilate
17
Carotid Filter Issues Should I Pre-dilate Before Filter Placement?
Carotid Complex Lesion Morphology Sharp Entry Angle Sharp Exit Angle Absent clear path through Lesion Subtotal
18
Carotid Filter Issues What to do when filter doesn't advanve?
Power Guide support Pre-dilatation Buddy-wire Buddy-Catheter Bare wire/Spyder proximal Protection Percusurge
19
Carotid Filter Issues What to do with slow flow / occluded Filter ?
Filling defect below filter dots Aspirate with, e.g.Diver® Close Filter Filling defect above filter dots Close filter and remove Incidence slow flow % Aspiration 2-5%
20
Carotid Filter Issues What to do with slow Flow/ Occluded filter?
Are filter Dots Closed? Yes Carotid spasm Give Nitro No Filter slow flow due to emboli Retrieve Filter
21
Asymptomatic Flow Obstruction
Spasm
22
Asymptomatic Flow Obstruction
Filled Filter
23
Filter Detachment RC Catheter advancement problem
Filter Slides down and impinges on stent Guide catheter prolapse into Aorta pulls Filter down
24
Filter Detachment Preventive Strategies Avoid cases with poor landing
zone Always keep guide tip in view Never force to pull the Filter into RC Change RC Type (Accunet?)
25
Carotid Filter Issues What to do when Retrieval
Catheter doesn't advance? Anatomical Adversity Issues Carotid Tortuosity Sharp Lesion Angles Guide Wire bias Inadequate post dilatation Open cell stent design with "gater backing" Calcified lesion
26
Carotid Filter Issues What to do when Retrieval
Catheter does not advance? Don't panic and pull on filter! Neck rotation Advance sheath distally Bent tip retrieval sheath Buddy-wire Additional balloon dilatations Neck Compression
27
Carotid Stent Issues Should I Pre-dilate Before Stent-Placement?
Carotid Stent Profile Tip of Stent Delivery System Carotid Lesion Severity Carotid Tortuosity Operator Experience Carotid Lesion Complex Morphology Sharp Entry Angle Sharp Exit Angle Heavy Calcification
28
Should I Post Dilate After Stent Placement? Objectives
Minimal final lumen diameter Safe retrieval of DPD Open cell design stent Avoid stent migration
29
Hands off!
31
Take Home Message Avoid These S STEEP Arch (Type III)
SEVERE Tortuosity SHARP Entry Angle SHARP Exit Angle INSUFFICIENT Landing Zone UNSATISFACTORY Collaterals
32
Thank You for Your Attention!
Ralf Langhoff
Similar presentations
© 2025 SlidePlayer.com. Inc.
All rights reserved.